2023
PFD Reports
Reports: 552
Areas: 65
85% response rate (above 63% average).
Eifion Huws
All Responded
2023-0185
8 Jun 2023
North West Wales
Betsi Cadwaladr University Health Board
Concerns summary (AI summary)
Inadequate access to comprehensive patient records (due to electronic vs. hard copy discrepancies) hindered emergency staff decision-making. The Health Board's investigation also failed to address this critical information-sharing flaw or improve overall investigation timeliness.
Action Taken
(AI summary)
The Health Board is implementing the Welsh Community Care Information System (WCCIS) for integrated health and social care records and has reviewed its incident process, implemented rapid learning panels, and prioritized completion of overdue investigations and action plans.
David Wilson
All Responded
2023-0184
8 Jun 2023
West Yorkshire (Eastern)
Mid Yorkshire Hospitals NHS Trust
Concerns summary (AI summary)
The patient did not provide truly informed consent for a procedure because the standard form lacked statistical risk ratings, didn't tailor risks to his medical history, omitted the risk of death, and was signed while sedated.
Action Planned
(AI summary)
The Trust will refresh its consent policy ahead of its triennial review, and will work with clinical teams to ensure that as part of the consent process, the question of a patient’s capacity is considered, taken into account, and properly documented.
Ivan Ignatov
All Responded
2023-0182
8 Jun 2023
Dorset
College of Policing, National Police Ch…
Concerns summary (AI summary)
A detainee's mental health assessment was missed in police custody, and an act of self-harm was misjudged. Critical risk information, including first-time custody status, was not properly recorded or collated, hindering comprehensive risk assessment.
Noted
(AI summary)
Dorset and Wiltshire Fire and Rescue Service states its commitment to the Joint Emergency Services Interoperability Principles (JESIP) and highlights that the challenges of intra-operability with partners is an area of focus for the Blue Light Group on 18 September 2023. Dorset Police has updated the Niche system by adding a drop-down list regarding Google Translate translation software. They are also implementing changes to Section 2 of Occurrence Logs on Niche, to prompt the Custody personnel to consider risk and vulnerability regarding the detainee in question. HM Coastguard updated its Capability Matrix to provide partner emergency services across the UK with information on its communications capabilities and uploaded it to the MCA's ResilienceDirect page. 'Connect' call capabilities also now feature in routine exercising with other stakeholders and during the Emergency Control Room visits. The National Fire Chiefs Council (NFCC) supports the consistent and robust embedding of the Joint Emergency Services Interoperability Programme (JESIP) doctrine and will commence work in autumn 2023 to establish a process of providing additional national assurance about the application of JESIP across blue light services. The Trust outlines its existing communication protocols with other emergency services, including ambulance dispatchers' ability to communicate with air ambulances and telephone links with SAR aircraft via the Maritime and Coastguard Agency. It says its staff endeavour to use clear language in all communications, adhering to JESIP principles. NHS England acknowledges concerns but notes many fall outside its remit. It encourages local systems to consider accessibility of resources and highlights agreed actions between Dorset Healthcare Criminal Justice Liaison and Diversion Team and Dorset Police to improve working practices. The College of Policing will amend the Detention and Custody APP checklist to include a question about previous arrests. Once this amendment has been made the College will write to forces informing them of the change. AACE will work with partners in police, fire and rescue, and search and rescue and the matter of concern will be discussed at the UKSAR Communications working group. The Medical Advisor to NARU is aware of the concerns and is looking to ensure learning from this tragic incident takes place. NPAS and HMCG have agreed to a series of joint familiarisation briefings for all staff and will develop a joint "quick action card" prioritising the need for the Host Force to set an Emergency Services channel on Airwave. Monthly Comms meetings and quarterly meetings will be held and reciprocal visits between the HMCG / NPAS Ops Centres will be arranged. The RNLI is updating its page on the government's "ResilienceDirect" platform with details about its capabilities and pulling together material to be shared directly with emergency services partners. The RNLI will also work with the Coastguard to participate in partner awareness 'open day' events. NicheRMS circulated the facts of the coroner's report to Niche Technology customers and is seeking views on changes needed to reduce the chance of a similar occurrence. A temporary solution is proposed, pending consultation with all Niche forces, that will involve staff making the appropriate detention log entry as occurs for other risk assessment questions.
Brenda Shields
All Responded
2023-0191
7 Jun 2023
Cumbria
Northumberland, Tyne and Wear NHS Trust
Concerns summary (AI summary)
The patient was discharged without planned follow-up or family involvement, and promised referrals were not made. Inadequate consideration of her alcohol problems led to an incorrect low-risk assessment, mirroring concerns from previous reports.
Noted
(AI summary)
The Trust clarifies the extent of family involvement in the patient's discharge and references its Service User and Carer involvement Strategy but does not describe specific actions taken or planned in direct response to the concerns.
Anthony Smith
All Responded
2023-0187
7 Jun 2023
Lancashire and Blackburn with Darwen
HM Prison and Probation Service
Concerns summary (AI summary)
The absence of protective mouth masks for resuscitation in prison exposes resuscitators to the risk of blood-borne viruses and could deter life-saving rescue breaths.
Action Taken
(AI summary)
The First Aid Policy Framework is being re-issued with instructions on face shield use, requiring all first aid kits to contain them and for them to be monitored. Face shields have been purchased and added to first aid boxes at HMP Preston, and staff were notified.
David Wood
All Responded
2023-0181
7 Jun 2023
Milton Keynes
John Radcliffe Hospital and MK together…
Concerns summary (AI summary)
There was a failure to communicate delirium symptoms to the GP and educate the family on post-surgical discharge care, highlighting a need to review discharge protocols following heart surgery.
Action Taken
(AI summary)
The POA clerking proforma was amended to include previous mental health and substance use. A discharge coordinator was appointed, and the nursing team educated on support services. Consent-form stickers were updated to include delirium as a possible complication, and the process for psychological medicine referrals was clarified.
Alexander Blewitt
All Responded
2023-0207
6 Jun 2023
Milton Keynes
Milton Keynes University Hospital, Care…
Concerns summary (AI summary)
The coroner notes concerns about the lack of reliable recording of intravenous fluids in the emergency department, missed points during triage, and a failure to record a major presenting symptom by the treating doctor; the Incident Investigation Report was also found to be of a poor standard.
Action Planned
(AI summary)
The hospital is implementing mandatory training for ED staff on referral note review, accurate medication documentation, and sepsis protocols. The Chief Nurse and Medical Director will write to all registered ED staff to emphasize key issues from the case.
Jonathan Cole
All Responded
2023-0186
5 Jun 2023
Derby and Derbyshire
Ministry of Defence
Nottinghamshire Healthcare NHS Foundati…
Concerns summary (AI summary)
There is a critical shortage of psychiatrists and psychologists within the Ministry of Defence, impacting serving personnel's access to appropriate mental health diagnosis and treatment, compounded by ongoing recruitment difficulties.
Noted
(AI summary)
The Ministry of Defence outlines existing strategies and policies related to mental health support for military personnel, transition to civilian life, and assistance to veterans and describes reviews of the Armed Forces Compensation Scheme but does not describe specific actions taken or planned in direct response to the concerns. The Trust has developed guidance for investigators to consider neurodiversity and reasonable adjustments. They will also proactively review completed investigations and upcoming inquests to identify further learning, ensure family engagement, and summarize key themes to support improvement work.
Nigel Harper
All Responded
2023-0179
2 Jun 2023
Worcestershire
Herefordshire and Worcestershire Health…
Concerns summary (AI summary)
A critical communication breakdown between two NHS Trusts led to a patient with suicidal thoughts not receiving an intended urgent mental health assessment. This misunderstanding of urgent referral protocols poses a risk of future deaths.
Action Taken
(AI summary)
Senior managers from Gloucestershire Health & Care NHS Foundation Trust and Herefordshire & Worcestershire Health & Care Trust have met to discuss how their mental health urgent care services operate and shared operational policies. The Mental Health Liaison Team has strengthened its SOP regarding inter-trust referrals, including email confirmation and EPR entries, with an audit planned in six months. Herefordshire and Worcestershire Health and Care NHS Trust updated its standard operating procedure to clarify the nature/purpose and urgency of referrals to out-of-county emergency services, documenting the outcome on Carenotes and requiring a comprehensive assessment from the referrer.
Andrew Dean
All Responded
2023-0178
2 Jun 2023
East Sussex
HM Prison and Probation Service
Concerns summary (AI summary)
There are no clear prison procedures for ensuring new prisoners can make initial family contact or for handling incoming calls from family members concerned about a prisoner's safety, posing a risk of future self-harm or suicide.
Action Taken
(AI summary)
HMPPS is rolling out electronic logging of safer custody concerns to all prisons by March 2024, with HMP Lewes receiving on-site support in December 2023. Staff have been instructed to record welfare calls and pass information to duty officers immediately.
Andrew Shambrook
All Responded
2023-0177
31 May 2023
North Wales East and Central
Betsi Cadwaladr University Health Board
Concerns summary (AI summary)
The health board lacks a robust, documented policy for decision-making and care pathways when patients are referred to the Home Treatment Team.
Action Planned
(AI summary)
The Health Board will review and ratify its Home Treatment Team Operational Policy by 31 January 2024, incorporating the coroner's comments. An interim addendum has been created to address immediate concerns.
Carol Clements
All Responded
2023-0175
30 May 2023
Birmingham and Solihull
Birmingham Community Healthcare NHS Fou…
Concerns summary (AI summary)
Mandatory training lacks enhanced supervision levels, and falls risk assessment training for new and agency staff is inadequate. Audits of falls risk assessments only check compliance, not correctness, failing to identify errors or training gaps.
Action Planned
(AI summary)
An in-depth action plan is being created to improve falls assessment training, enhanced supervision training, and auditing of falls risk assessments, to be approved by the Chief of Nursing and Therapies by 25 July 2023. Spot check reviews of falls risk assessments will be undertaken as part of care rounding, and a quarterly falls prevention effectiveness audit will be developed.
Conrad Colson
All Responded
2023-0173
26 May 2023
East London
Department of Health and Social Care
NHS England and Tatiana Aesthetic Derma…
North East London Foundation Trust
+2 more
Concerns summary (AI summary)
There was a lack of liaison and information sharing between specialist and step-down mental health services, particularly regarding discharge risks and Body Dysmorphic Disorder (BDD) treatment. Training on BDD and its associated risks, including aesthetic dermatology, is insufficient, compounded by a lack of national BDD resources.
Action Planned
(AI summary)
CADAT has updated its discharge policy to explicitly state the expectations of liaison between local teams and how staff are expected to communicate with skin clinics regarding patients seeking aesthetic dermatological/cosmetic treatment. The updated policy was reviewed and ratified by the PMOA Leadership Team on 12 July 2023. NHS England's Clinical Reference Group (CRG) for OCD & BDD intends to convene with stakeholders to consider issues of patients with BDD accessing aesthetic dermatology treatments. They have asked to be sighted on the responses to the Report from both NEFLT and SLAM and will consider these carefully. NELFT is developing actions including care pathway mapping, updating the risk assessment process, and arranging BDD training for all staff in conjunction with SLAM. A Quality Improvement Project will be undertaken to understand gaps in risk assessment and risk management processes, and a workstream is leading on the development of risk formulation. The clinic updated its BDD policy to include formal screening for BDD using the COPS questionnaire, updated the patient journey policy regarding communication and information sharing, and provided in-depth, mandatory training on the revised BDD policy to all staff on 14th June 2023. They also commenced a daily team brief to discuss patients and highlight those needing a BDD screen.
Jean Hardy
All Responded
2023-0176
25 May 2023
Newcastle upon Tyne and North Tyneside
Sunderland City Council
Concerns summary (AI summary)
Pedestrians commonly cross a busy road at non-designated points due to lack of fencing and warning signage. A comprehensive review of pedestrian crossing provision is needed to prevent future deaths.
Action Planned
(AI summary)
The council is proposing to install signage on both sides of Doxford Parkway to direct pedestrians to nearby crossing points.
Michael Bray
All Responded
2024-0238
22 May 2023
Suffolk
Department of Health and Social Care
East of England Ambulance Service NHS T…
Concerns summary (AI summary)
Ambulance response times for Category 2 calls are persistently and significantly below target, posing a risk of future deaths. Current actions to address these long delays have been demonstrably ineffective.
Action Planned
(AI summary)
The East of England Ambulance Service has an Organisational Performance and Improvement Plan (OPIP) to improve response times. The plan includes actions to improve national performance benchmarking and increase the work-effective workforce; they are continuing to work with NHS England and other healthcare partners to improve response times, particularly in relation to Category 2 calls. The Department of Health and Social Care's response highlights the Delivery plan for recovering urgent and emergency care services, which aims to improve ambulance response times by increasing capacity, improving patient flow, and expanding virtual ward capacity. They report improvements in Category 2 ambulance response times nationally and within the East of England Ambulance Service.
Kaius Tutt
All Responded
2023-0169
22 May 2023
Cornwall and the Isles of Scilly
Connectivity and Environment
Concerns summary (AI summary)
Faded road markings and visibility issues at a roundabout create hazardous conditions. A recommendation to remove a dangerous downhill overtaking section lacks funding for implementation.
Action Taken
(AI summary)
The Highway Authority has arranged for the relevant downhill overtaking section to be removed on the A391 at Carclaze, St Austell.
Amelia Barbosa
All Responded
2023-0167
19 May 2023
Cambridgeshire and Peterborough
North West Anglia NHS Foundation Trust
Concerns summary (AI summary)
Inadequate training means midwives still take inaccurate cord blood samples, leading to false reassurances. There is also a lack of training on UVC/IO access and blood transfusions for neonatal resuscitation.
Action Planned
(AI summary)
OPSS will assess the safety and compliance of similar baby bath seat models and work with the Baby Products Association to remind members of safety requirements. They will also ask the NHS to consider including safety messages related to baby bath seats in their communications. Following the inquest, the midwifery department has produced and issued a poster clarifying that cord blood samples must be taken from the clamped area and the neonatal resuscitation trolley is now routinely stocked with short intraosseous needles.
Norma Bruton
All Responded
2023-0165
19 May 2023
Birmingham and Solihull
University Hospitals Birmingham NHS Fou…
Concerns summary (AI summary)
The hospital's falls risk assessment form inadequately prompts staff to consider or document the presence and relevance of patient attachments, such as chest drains or IV infusions, in relation to falls risk.
Action Planned
(AI summary)
The Trust will add a drop-down menu to the falls risk assessment to allow staff to record any equipment such as drains, and this will also be recorded in the Patient Handling Assessment Form. This change is expected to be implemented on 15th August 2023.
Akash Bhudia
All Responded
2023-0164
18 May 2023
East London
Medica Reporting Service
Concerns summary (AI summary)
Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the patient had been discharged. There is no clear process for alerting referrers to such critical changes in non-inpatient cases.
Action Taken
(AI summary)
Medica have edited their Medica Alerts policy to include a potential new diagnosis of TB as a reason to raise an urgent notification to referrers, and this has been circulated to all reporters. They will also work with clients to enact the Academy of Royal College/RCR Alerts guidelines 2022.
Samuel Morgan
All Responded
2023-0163
18 May 2023
Swansea Neath Port Talbot
Swansea Bay University Health Board
Concerns summary (AI summary)
A lack of integrated electronic records between alcohol/drug addiction and mental health services prevents effective information sharing, particularly for complex dual diagnosis cases. This poses a significant risk that critical patient safety information will be lost between agencies.
Action Planned
(AI summary)
For Swansea based teams, technical changes to enable two-way information sharing between community mental health teams and drug and alcohol services via WCCIS will be completed within 10 working days, commencing 7th August 2023. For NPT based teams, access to WCCIS on a read-only basis will be extended, with implementation planned from 4th September 2023.
Mark Ravensdale
All Responded
2025-0400
16 May 2023
South Yorkshire (West District)
South West Yorkshire Partnership NHS Fo…
Concerns summary (AI summary)
Mental health services failed to directly engage with the deceased to properly and adequately assess his mental health condition.
Action Planned
(AI summary)
The Trust will develop and implement a triage checklist for their Single Point of Access (SPA) teams, with an initial study of its impact undertaken after 6 months of implementation. This is in response to concerns about direct contact with individuals during triage.
Stuart Robinson
All Responded
2023-0161
16 May 2023
Liverpool and Wirral
Ministry of Justice (Coroners)
Concerns summary (AI summary)
Prison ACCT reviews lacked mandatory mental health expert attendance, leading to missed opportunities to identify and support prisoners with mental health issues. This meant self-harm was not adequately addressed.
Noted
(AI summary)
HMPPS emphasizes that the ACCT case management approach is designed to meet the specific needs of the individual by providing multi-disciplinary support. Healthcare staff are always invited to the first case review to consider the need for any additional mental health support.
Roger Southwick
All Responded
2023-0158
16 May 2023
Manchester South
Tameside and Glossop Integrated Care NH…
Concerns summary (AI summary)
The report identifies failures to accurately complete a Falls Risk Assessment and to reassess the risk after family members reported the deceased's compromised mobility; the Trust's Investigation Report also failed to address these issues.
Action Taken
(AI summary)
The Trust already holds daily ward safety huddles to discuss patients at risk of falls, and has a number of existing practices and processes for falls prevention in place. They also held a "Focus on Falls Week" in September 2022 which is now an annual event.
Carl Thompson
All Responded
2023-0157
16 May 2023
Manchester South
Pennine Care NHS Foundation Trust
Concerns summary (AI summary)
Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance misuse, led to missed opportunities for intervention. The patient was not seen face-to-face as policy required and lacked a dedicated care coordinator, while the Trust's action plan remains uncompleted.
Action Taken
(AI summary)
The trust has revisited its investigation report to support review of action plans, re-established a Just Culture meeting, is considering updated training for investigation authors, established a PSIRF implementation group, made patient safety training available online, and planned to share learning slides around inquest preparation.
Benedict Peters
All Responded
2023-0156
16 May 2023
Manchester South
Manchester University NHS Foundation Tr…
Concerns summary (AI summary)
A patient with cardiac symptoms and family history was discharged from Ambulatory Care without a doctor's in-person examination or review. The Trust lacks a policy or protocol for discharging patients without medical review.
Action Planned
(AI summary)
The Trust will remind all Physician Associates of the need to discuss patients for discharge with senior medical colleagues and reiterate to all junior medical staff and non-medical clinical practitioners, that it remains good practice to discuss cases with their seniors for learning and development.